Management of Anticoagulation/Antiplatelet Medication and Venous Thromboembolism Prophylaxis in Elective Spine Surgery: Concise Clinical Recommendations Based on a Modified Delphi Process.

STUDY DESIGN: Delphi method. OBJECTIVE: To gain consensus on the following questions: (1) When should anticoagulation/antiplatelet (AC/AP) medication be stopped before elective spine surgery?; (2) When should AC/AP medication be restarted after elective spine surgery?; (3) When, how, and in whom should venous thromboembolism (VTE) chemoprophylaxis be started after elective spinal surgery? SUMMARY OF BACKGROUND DATA: VTE can lead to significant morbidity after adult spine surgery, yet postoperative VTE prophylaxis practices vary considerably. The management of preoperative AC/AP medication is similarly heterogeneous. MATERIALS AND METHODS: Delphi method of consensus development consisting of three rounds (January 26, 2021, to June 21, 2021). RESULTS: Twenty-one spine surgeons were invited, and 20 surgeons completed all rounds of questioning. Consensus (>70% agreement) was achieved in 26/27 items. Group consensus stated that preoperative Direct Oral Anticoagulants should be stopped two days before surgery, warfarin stopped five days before surgery, and all remaining AC/AP medication and aspirin should be stopped seven days before surgery. For restarting AC/AP medication postoperatively, consensus was achieved for low-risk/medium-risk/high-risk patients in 5/5 risk factors (VTE history/cardiac/ambulation status/anterior approach/operation). The low/medium/high thresholds were POD7/POD5/POD2, respectively. For VTE chemoprophylaxis, consensus was achieved for low-risk/medium-risk/high-risk patients in 12/13 risk factors (age/BMI/VTE history/cardiac/cancer/hormone therapy/operation/anterior approach/staged separate days/staged same days/operative time/transfusion). The one area that did not gain consensus was same-day staged surgery. The low-threshold/medium-threshold/high-threshold ranges were postoperative day 5 (POD5) or none/POD3-4/POD1-2, respectively. Additional VTE chemoprophylaxis considerations that gained consensus were POD1 defined as the morning after surgery regardless of operating finishing time, enoxaparin as the medication of choice, and standardized, rather than weight-based, dose given once per day. CONCLUSIONS: In the first known Delphi study to address anticoagulation/antiplatelet recommendations for elective spine surgery (preoperatively and postoperatively); our Delphi consensus recommendations from 20 spine surgeons achieved consensus on 26/27 items. These results will potentially help standardize the management of preoperative AC/AP medication and VTE chemoprophylaxis after adult elective spine surgery.

Minimally invasive approach to the lumbosacral junction with a single position, 360° fusion.

Degenerative lumbar pathologies are commonly encountered at the lumbosacral junction. The transition from the mobile lumbar spine to the stiff sacroiliac segment results in high biomechanical stresses and can lead to disc degeneration, ligamentum flavum hypertrophy, neural foraminal stenosis, and other causes of pain or neurologic deficit. Surgical intervention at the lumbosacral junction must be tailored to maximize pain relief and relieve neural compression and reverse neurologic deficit while preserving the spine's natural biomechanical strength and flexibility and preventing the slow march of adjacent segment degeneration cranially into the thoracolumbar spine. It is our practice to offer combined anterior and posterior minimally invasive options when appropriate to maximize neural decompression and pain relief while ensuring proper segmental alignment and maximizing fusion rates through a minimally disruptive approach. In this article we detail a common presentation of lumbosacral pathology and the approach and considerations for a single position, minimally invasive anterior and posterior approach at the L5/S1 segment.

Duplex-guided endovascular treatment for occlusive and stenotic lesions of the femoral-popliteal arterial segment: a comparative study in the first 253 cases.

OBJECTIVE: The standard technique of balloon angioplasty with or without subintimal dissection of infrainguinal arteries requires contrast arteriography and fluoroscopy. We attempted to perform this procedure with duplex guidance to avoid the use of nephrotoxic contrast material and eliminate or minimize radiation exposure. METHODS: From September 2003 to June 2005, 196 patients (57% male) with a mean age of 73 +/- 10 years (range, 42-97 years) had a total of 253 attempted balloon angioplasties of the superficial femoral and/or popliteal artery under duplex guidance in 218 limbs. Critical ischemia was the indication in 38% of cases, and disabling claudication was the indication in 62%. Hypertension, diabetes, chronic renal insufficiency, smoking, and coronary artery disease were present in 78%, 51%, 41%, 39%, and 37% of patients, respectively. The TransAtlantic Inter-Society Consensus (TASC) classification was used for morphologic description of femoral-popliteal lesions. The common femoral artery was cannulated under direct duplex visualization. Still under duplex guidance, a guidewire was directed into the proximal superficial femoral artery, across the diseased segment(s), and parked at the tibioperoneal trunk. The diseased segment(s) were then balloon-dilated. Balloon diameter and length were chosen according to arterial measurements obtained by duplex scan. Hemodynamically significant defects causing diameter reductions greater than 30% and peak systolic velocity ratios greater than 2 were stented with a variety of self-expandable stents under duplex guidance. Completion duplex examinations and ankle-brachial indices were obtained routinely before hospital discharge. RESULTS: There were 11 (4%) TASC class A lesions, 31 (12%) TASC class B lesions, 177 (70%) TASC class C lesions, and 34 (14%) TASC class D lesions in this series. The overall technical success was 93% (236/253 cases). Eight of the 17 failed subintimal dissections belonged to TASC class C and the remaining 9 to TASC class D. End-stage renal disease was the only significant predictor of subintimal dissection failure in patients with femoral-popliteal occlusions (5/17 cases; P < .04). Intraluminal stents were placed in 153 (65%) of 236 successful cases. Overall pre-procedure and post-procedure ankle-brachial indices changed from a mean of 0.69 +/- 0.16 (range, 0.2-1.1) to 0.95 +/- 0.14 (range, 0.55-1.3), respectively (P < .0001). The mean duration of follow-up was 10 +/- 7 months (range, 1-29 months). The overall 30-day survival rate was 100%. Overall limb salvage rates were 94% and 90% at 6 and 12 months, respectively. Six-month patency rates for TASC class A, B, C, and D lesions were 89%, 73%, 72%, and 63%, respectively. Twelve-month patency rates for TASC class A, B, C, and D lesions were 89%, 58%, 51%, and 45%, respectively. CONCLUSIONS: Duplex-guided balloon angioplasty and stent placement seems to be a safe and effective technique for the treatment of infrainguinal arterial occlusive disease. Technical advantages include direct visualization of the puncture site, accurate selection of the proper size balloon and stent, and confirmation of the adequacy of the technique by hemodynamic and imaging parameters. Additional benefits are avoidance of radiation exposure and contrast material.

Regional anesthesia: preferred technique for venodilatation in the creation of upper extremity arteriovenous fistulae.

Owing to the overall poor medical health of patients with end-stage renal disease, we have sought alternatives to the use of general anesthesia for access procedures. Furthermore, since local anesthesia (1) does not offer the motor block that is sometimes desired and (2) can be difficult to maintain when a large amount of vein needs to be transposed, we examined whether regional blocks can be useful for the creation of new arteriovenous fistulae (AVF). From August 2002 to January 2005, 41 patients scheduled for AVF placement underwent a regional block with the use of a lidocaine and ropivacaine mixture using a nerve stimulator. Either axillary, interscalene, or infraclavicular blocks or a combination was used. Intraoperative duplex ultrasonography was used to assess the degree of venodilatation of the basilic and cephalic veins before and after the block. The site of each measurement was marked on the skin and selected by a clearly identifiable branch point. Each measurement was recorded three times and was made in the (1) native state, (2) after application of a tourniquet with opening and closing of the hand for 15 seconds, and (3) after placement of the block. The average age of the patients was 65 +/- 14 years (SD), with ages ranging from 33 to 91 years, and the prevalence of diabetes mellitus was 50%. Complete brachial plexus block was achieved in 34 patients (83%). Sensory block was accomplished within 10 to 15 minutes and usually lasted 4 to 6 hours. Motor block was accomplished in 10 to 25 minutes. Venodilatation was not noted in patients whose blocks did not work (n = 7) or whose vein was found to be phlebitic on exploration (n = 3). The degree of venodilatation noted as a percentage increase after application of the tourniquet compared with the native state for these 34 patients (in whom the block worked) was 37% for the distal cephalic, 31% for the midcephalic, and 32% for the midbasilic vein. The degree of venodilatation noted as a percentage increase after placement of the block compared with after tourniquet application for these 34 patients was 42% for the distal cephalic, 19% for the midcephalic, and 26% for the midbasilic vein. No instances of systemic toxicity, hematomas, or nerve injury from the block were noted. Accesses placed included 20 radiocephalic AVF, 8 brachiobasilic AVF, 8 brachiocephalic AVF, 2 arteriovenous grafts, 2 radiobasilic AVF, and 1 brachial vein AVF.Regional block is a safe and, in our opinion, preferred technique for providing anesthesia for upper extremity vascular surgery. The venodilatation observed is augmented compared with that using a tourniquet and may allow more options for access placements.

Morbidity and mortality associated with brachial vein thrombosis.

We have noted a significant incidence of pulmonary embolism (PE) and mortality associated with upper extremity deep venous thrombosis (UEDVT). Since there is an association between site of lower extremity DVT (LEDVT) and PE, we hypothesized that there might also be a correlation between site of UEDVT and PE with associated mortality. To further elucidate this hypotheses, we analyzed the mortality and incidence of PE diagnosed with subclavian/axillary/internal jugular vein thrombosis during an 11-year period at our institution and compared the data to those of patients diagnosed with brachial DVT. We studied 598 patients diagnosed with acute internal jugular, subclavian, axillary, or brachial DVT by duplex scanning. The patients were divided into three groups based on the most proximal location of the thrombus: group I, UEDVT involving the subclavian or axillary veins (n = 467); group II, isolated internal jugular DVT (n = 80); group III, brachial DVT alone (n = 52). Mortality rates at 2 months were 29%, 25%, and 21% for each group, respectively. The number of patients diagnosed with PE by ventilation/perfusion scans in groups I, II, and III, respectively, were 5%, 6.25% and 11.5% (p = 0.13). Furthermore, stratification by risk factors failed to demonstrate factors associated with increased 2-month mortality. Contrary to the initial hypothesis of a relationship between the site of thrombosis and the incidence of PE and mortality, these data demonstrated no statistical differences in mortality or incidence of PE among the groups studied. Additionally, these data suggest that brachial vein thrombosis is a disease process related to comparable associated mortality and morbidity similar to other forms of UEDVT. Based on these data, we suggest that UEDVT may be thought of as a marker for the severity of systemic illness of the patient rather than just as a cause of venous thromboembolism.

Prospective evaluation of combined upper and lower extremity DVT.

The clinical importance of upper extremity deep venous thrombosis (UEDVT) has been increasingly demonstrated in recent literature. Not only has the risk of pulmonary embolism from isolated upper extremity DVT been demonstrated, but a significant associated mortality has been encountered. Examination of this group of patients has demonstrated the existence of combined upper and lower extremity deep venous thrombosis (DVT) in some patients who exhibit an even higher associated mortality. As a result of this information, it has become the standard practice at this institution to search for lower extremity DVTs in patients found to have acute thrombosis of upper extremity veins. Since January 1999, there have been a total of 227 patients diagnosed with acute UEDVT. Within this group, 211 (93%) patients had lower extremity studies; 45 of these 211 (21%) had acute lower extremity DVTs by duplex examination in addition to the upper extremity DVTs. Overall, there were 145 women, 66 men, and the average age was 70 +/-1.2 (SEM); 22 of these patients had bilateral lower extremity thrombosis (LEDVT), and 8 patients were found to have chronic thrombosis of lower extremity veins. Of the patients with bilateral upper extremity DVTs, there were 3 with bilateral LE acute DVTs. Finally, 8 of the remaining 166 patients (5%) with originally negative lower extremity studies were found to develop a thrombosis at a later date. These data serve to confirm previous studies, on a larger scale, that there should be a high index of suspicion in patients with UEDVT of a coexistent LEDVT.

Mini skin incision for carotid endarterectomy (CEA): a new and safe alternative to the standard approach.

PURPOSE: Patients requiring surgery are naturally attracted to shorter incisions because they tend to cause less pain and are esthetically more appeasing. To substantially shorten the length of standard skin incisions (4 to 7 inches) for carotid endarterectomy (CEA), we used preoperative duplex scanning to outline the carotid bifurcation as well as to determine the extent of disease in both the internal and common carotid arteries. METHODS: During the last 21 months, 265 consecutive primary CEAs were performed in 253 patients (mean age 72 +/- 10 years) at a single institution. Of these, 142 were men (56%). Hypertension, coronary artery disease, diabetes mellitus, smoking, and chronic renal failure were present in 81%, 44%, 43%, 28%, and 19% of the patients, respectively. Neurologically asymptomatic patients accounted for 71% of the cases. All patients received general anesthesia. Duplex-assisted skin markings of the diseased carotid artery were performed after proper patient positioning on the operating table. Synthetic patches were routinely used, and intraluminal shunts were deemed necessary by low stump pressures in 64 cases (24%). Completion duplex scanning was performed in all cases. RESULTS: The length of the longitudinal skin incision varied from 0.8 to 3.5 inches (average 1.4 +/- 0.5 inches). It was < or = 1 inch in 56 cases (21%), 1.1 to 1.5 inches in 110 (42%), 1.6 to 2 inches in 85 (32%), and 2.1 to 3.5 inches in the remaining 14 cases (5%). Intraluminal shunts were required in 9 (16%), 18 (16%), 29 (34%), and 8 (57%) of the cases, respectively. Incisions were longer in cases requiring an indwelling shunt (1.6 +/- 0.6 inches vs 1.4 +/- 0.4 inches) (P < .0001). The average patch length was 1.3 +/- 0.3 inches (range, 0.7 to 2.6 inches). The skin incision averaged 1.54 +/- 0.45 inches for the first 133 cases and 1.35 +/- 0.45 inches for the remaining 132 cases (P < .0001). Technical defects occurred in 10 cases (3.8%). The overall incidence of ipsilateral stroke and death was 1.9% and 0%. There were no technical defects or strokes in patients with the shortest incisions (< or = 1 inch). Overall, there were three transitory peripheral nerve injuries (1.1%). A comparative analysis with 265 consecutive CEAs performed immediately before this series without duplex-assisted skin markings revealed no significant differences in age (71 +/- 11 years), incidence of neurologically symptomatic patients (26%), sex (60% men), shunt use (24%), and major technical defects (3%). Also, postoperative transitory peripheral nerve injury (0.8%), stroke (0%), and death (0%) were not significantly different from the duplex-assisted group. It is of interest to note that none of the former cases was performed with a skin incision < or = 2 inches. CONCLUSION: Most CEAs (95%) can safely be performed with < or = 2-inch skin incisions. Pre-CEA duplex-assisted skin marking is a novel approach that confirms the side of the operation, localizes the disease, and minimizes the magnitude of the operation via shorter, more esthetically pleasing incisions.

Duplex-guided balloon angioplasty and stenting for femoropopliteal arterial occlusive disease: an alternative in patients with renal insufficiency.

BACKGROUND: The technique of balloon angioplasty of infrainguinal arteries requires standard arteriography and fluoroscopic guidance. We attempted to perform this procedure under duplex guidance to avoid the use of nephrotoxic contrast material and radiation exposure in patients with renal insufficiency. METHODS: Over 16 months, 28 patients (17 men) with serum creatinine levels of 1.5 mg/dL or more underwent 37 lower extremity duplex-guided balloon angioplasties at our institution. Ages ranged from 58 to 92 years (mean +/- SD, 74 +/- 9 years). Disabling claudication was the indication in 24 cases (65%), and critical ischemia, in 13 cases. Preoperative duplex arterial mapping showed severe superficial femoral artery and/or popliteal artery stenoses in all cases. No arterial occlusions were treated in this series. Seven procedures (19%) were performed for restenosis. The ipsilateral common femoral artery was cannulated in 32 cases (86%), and the contralateral common femoral artery, in 5 cases (14%), under direct duplex visualization. Contralateral common iliac artery cannulations were performed with the help of fluoroscopy. By using sonographic visualization, a guidewire was directed into the origin of the superficial femoral artery, across the diseased segment, and into the popliteal artery. The diseased segment was then balloon-dilated. Balloon diameter and length were chosen according to arterial measurements obtained by duplex scan. Plaque dissections and recoils causing stenosis of 30% or more, a peak systolic velocity ratio of 2 or more, or both were stented under duplex guidance. Arterial duplex examinations and ankle/brachial indexes were obtained before hospital discharge, within 1 month after the procedure, and every 3 months thereafter. RESULTS: Thirty-day survival was 100%. Local complications included one open exploration for expanding hematoma. Technical success was achieved in all cases. Placement of intraluminal stents was deemed appropriate in 23 (62%) of 37 cases. The 1-month patency and limb salvage rates were 100%. Preprocedure and postprocedure ankle/brachial indexes ranged from 0.3 to 0.9 (mean +/- SD, 0.64 +/- 0.16) and 0.64 to 1.2 (mean +/- SD, 0.92 +/- 0.15), respectively (P < .0001). CONCLUSIONS: Duplex-guided balloon angioplasty seems to be a safe and effective technique that allows renal patients to experience continued limb salvage and relief from claudication without the risk of developing dye-induced acute renal failure. Other advantages include direct visualization of the puncture site, accurate selection of the proper size of balloon and stent, confirmation of the adequacy of the technique by hemodynamic and imaging parameters, and avoidance of radiation. Although this technique holds considerable potential, longer follow-up will help to fully evaluate its broader applicability.

Duplex-guided balloon angioplasty and subintimal dissection of infrapopliteal arteries: early results with a new approach to avoid radiation exposure and contrast material.

OBJECTIVE: Balloon angioplasties of stenotic or occluded infrapopliteal arteries may be helpful in selected high-risk patients threatened with limb loss. Thus far, these procedures have demanded fluoroscopy and the injection of potentially nephrotoxic contrast material. Herein, we proposed a new alternative to avoid the harmful effects of radiation exposure and the risk of acute renal failure. METHODS: Over the last 16 months, 30 patients (57% male) aged 74 +/- 9 years (mean +/- SD) had a total of 52 attempted balloon angioplasties of the infrapopliteal arteries in 32 limbs under duplex guidance. Indications for the procedure were critical ischemia in 20 limbs (63%), including rest pain, ischemic ulcers, and gangrene in 4 (13%), 10 (31%), and 6 (19%) limbs, respectively. Severe disabling claudication was an indication in the remaining 12 limbs (37%). All patients had concomitantly performed balloon angioplasties of the superficial femoral and popliteal arteries (28 cases) or the popliteal artery alone (4 cases). Balloon angioplasty of the infrapopliteal arteries was performed as an adjunct to improve runoff. Hypertension, diabetes, renal insufficiency, smoking, and coronary artery disease were present in 77%, 73%, 50%, 47%, and 37% of cases, respectively. There were 42 cases (81%) with infrapopliteal arterial stenoses (25 tibioperoneal trunks, 9 peroneal arteries, 4 anterior tibial arteries, and 4 posterior tibial arteries) in 26 limbs. The remaining 10 cases (19%) had infrapopliteal arterial occlusions (4 tibioperoneal trunks, 5 peroneal arteries, and 1 anterior tibial artery) in 6 limbs. All these cases were combined with more proximal endovascular procedures (21 femoropopliteal stenoses and 11 femoropopliteal occlusions). All patients had preprocedure duplex arterial mapping and ankle/brachial index (ABI) measurement. Local anesthesia with light sedation was used in all cases. The common femoral artery was cannulated under direct duplex visualization. Still under duplex guidance, a guidewire was directed into the proximal superficial femoral artery and distally, beyond the infrapopliteal diseased segment. The diseased segment was then balloon-dilated. Balloon diameter and length were chosen according to the arterial measurements obtained by duplex guidance. Completion duplex examinations were performed and postprocedure ABIs were obtained in all cases. RESULTS: Although the overall technical success was 94% (49/52 cases), it was 95% for those with stenoses (40/42 cases) and 90% for those with occlusions (9/10 cases; P < .5). Intraoperative thrombosis occurred in three infrapopliteal cases (two tibioperoneal trunks and one peroneal artery) and in one popliteal artery. All four cases were successfully managed with intra-arterial infusion of thrombolytic agents under duplex guidance. Overall, the preprocedure and postprocedure ABIs ranged from 0.4 to 0.8 (mean +/- SD, 0.58 +/- 0.15) and 0.7 to 1.1 (mean +/- SD, 0.9 +/- 0.16), respectively (P < .0001). Twenty-two (88%) of 25 patients experienced a significant (> 0.15) postoperative ABI increase. Overall 30-day survival and limb salvage rates were 100%. CONCLUSIONS: The proposed technique eliminates the need for radiation exposure and the use of contrast material, and it seems to be an effective alternative approach for the treatment of infrapopliteal occlusive disease. Additional advantages include accurate selection of the proper size of balloon and confirmation of the adequacy of the technique by hemodynamic and imaging parameters.

A 10-year experience with complementary distal arteriovenous fistula and deep vein interposition for infrapopliteal prosthetic bypasses.

Since up to 20% of patients undergoing lower extremity revascularization do not have an adequate venous conduit, some authors have explored the use of prosthetic grafts with adjunctive techniques for lower extremity revascularization. However, the long-term graft patency of those procedures has not been well documented. The purpose of this study was to examine the long-term patency of polytetrafluoroethylene (PTFE) bypass with adjunctive arteriovenous fistula and venous interposition (AVF/VI) for infrapopliteal revascularization. Over a 10-year period, 246 lower extremity reconstructions were performed in 176 (71.5% men) patients with critical ischemia in whom a totally autogenous vein bypass was not feasible. Seventy-six limbs had undergone 1 or more failed ipsilateral infrainguinal bypasses. Indications for surgery were chronic critical limb-threatening ischemia (86%) (rest pain, ischemic ulcer, or gangrene) or acute ischemia (14%). Ages ranged from 46 to 91 years (mean 74 +/-0.6 [SD] years). Risk factors such as diabetes, hypertension, coronary artery disease, end-stage renal disease, and use of tobacco were present in 49%, 49%, 52%, 8%, and 67% of the patients, respectively. During the follow-up, 112 cases (45%) required reinterventions. Twenty-seven patients (15%) required bypass revision twice. During the follow up, 56 limbs (23%) were amputated (above-the-knee amputation 25 (10%); below-the-knee amputation 31 (13%). To date, 150 (85%) patients of a total of 176 are deceased. The primary graft patency rates were as follows: at 1 year, 51%; at 2 years, 41%; 3 years, 35%; and 5 years, 24%. Limb salvage rates were as follows: 1 year, 79%; 2 years, 76%; 3 years 76%; and 5 years, 74%. Patient survival rates were as follows: 1 year, 69%; 2 years, 60%; 3 years, 54%; and 5 years, 40%. Amputation-free patient survival rates were as follows: 1 year, 66%; 2 years, 57%, 3 years, 51%, and 5 years, 30%. This technique appears to offer reasonable patency and limb salvage rates in patients in whom autogenous bypass grafts are not feasible.

Effect of ultrasonography in the assessment of carotid artery stenosis.

Although ultrasonography (US) advantageously portrays lumen and wall thickness, velocity criteria have been used primarily to interpret carotid artery stenosis. The relationship of US and velocity measurements was investigated. Peak-systolic and end-diastolic velocities (PSV, EDV) increase exponentially as the lumen of the internal carotid artery narrows and the percent stenosis (%S) increases. We tested the consistency of the, relationship between carotid velocities and US %S in two distinct data sets. One data set was used to obtain regression equations relating velocity parameters and %S based on US. Validation of these equations was conducted using a separate, independent data set. US measurements were classified in 12 %S intervals, PSV, EDV, the ratio of the internal carotid artery to the common carotid artery PSV, and %S were entered consecutively until 10 records for each %S interval were obtained. Regression equations obtained in the first data set were used to predict %S in the second data set. Predicted %S was then compared with actual US %S. The highest correlation in the first data set (r = .89) was between %S and the natural logarithm (In) of PSV. This In PSV -%S equation was then applied to a second data set of an additional 120 carotid duplex images. In the second data set, actual %S and PSV-predicted %S differed by >10% in 38 cases (32%). When all velocity-%S regression equations were used for comparison, differences between actual and at least one velocity-predicted %S were >10% in 19% of the arteries. Conversely, actual %S matched at least one prediction of %S based on velocity data in 81% of the cases. US %S differed significantly from single velocity-based estimates of %S in at least one-third of the cases. On the other hand, four of five US measurements were confirmed by at least one velocity parameter. Emphasis on US, in addition to velocity data, is recommended for the interpretation of duplex US carotid examinations.

Duplex-assisted internal carotid artery balloon angioplasty and stent placement: a novel approach to minimize or eliminate the use of contrast material.

BACKGROUND: Carotid artery balloon angioplasty and stenting (CBAS) is emerging as an acceptable alternative to carotid endarterectomy in selected high-risk patients. Conversely, patients with pre-existing renal impairment, diabetes, or both may be harmed by the nephrotoxic contrast agents required during CBAS. We attempted to limit or eliminate the use of contrast material during CBAS. METHODS: Eighteen patients with severe carotid stenoses (>70%) underwent CBAS at our institution over the last 12 months with duplex scan-assisted CBAS. Of these, 12 were primary procedures, and 6 were performed for carotid re-stenosis. Fourteen patients (78%) were neurologically asymptomatic. The average age of these patients was 75 +/- 11 years (range, 44-92 years). Hypertension, chronic renal insufficiency (serum creatinine level > or =1.5 mg/dL), coronary artery disease, diabetes, and smoking were present in 89%, 67%, 59%, 33%, and 28% of patients, respectively. Preoperative duplex carotid mapping was performed in all cases. All procedures were performed with patients under local anesthesia and light sedation. RESULTS: An ATL HDI 5000 scanner with the SonoCT feature was used. The common femoral artery was cannulated with a single-entry needle under direct ultrasound visualization. Fluoroscopy was used to assist passage of the guidewire into the aorta and the common carotid artery. In only four cases (22%) was an aortic arch angiogram obtained. Selective catheterization of the internal and external carotid arteries was performed under ultrasound guidance. The distal cerebral protection device (17 cases) was placed under fluoroscopic guidance. Balloon width and length were chosen according to ultrasound measurements. Balloon and stent deployment were successfully achieved with ultrasound guidance alone in all cases. Appropriate stent apposition and resolution of the stenosis was confirmed by duplex scanning in all cases. Five patients (28%) were noted to have low (<100 mL/min) internal carotid artery volume flow after stent deployment (range, 20-88 mL/min; mean +/- SD, 50 +/- 25 mL/min). The internal carotid artery volume flow increased immediately after Filterwire retrieval in all cases and ranged from 136 to 400 mL/min (mean, 245 +/- 107 mL/min). This increase was statistically significant ( P < .02). No ipsilateral strokes or deaths occurred during follow-up from 1 to 12 months (mean follow-up, 5 months). CONCLUSIONS: Duplex scan-assisted CBAS is feasible and may reduce the need for intra-arterial contrast injection in selected patients deemed at high risk for renal failure from nephrotoxic contrast material. Additional advantages include direct visualization of the puncture site, precise position of the balloon and stent, and B-mode and hemodynamic confirmation of the adequacy of the technique.

Carotid endarterectomy in patients with chronic renal insufficiency: a recent series of 184 cases.

BACKGROUND: The published results of carotid endarterectomy (CEA) in chronic renal insufficiency (CRI) patients are contradictory, mostly because of the relatively small number of patients in these studies. To better assess the neurologic complications and mortality, we reviewed a recent and substantially larger series of CRI patients who underwent CEAs. METHODS: From March 2000 to March 2003, 675 consecutive primary CEAs were performed in 609 patients (346 men, 57%) under general anesthesia. Asymptomatic carotid artery stenosis accounted for 71% of cases. CRI (serum creatinine level > or = 1.5 mg/dL) was detected in 166 patients (27%) who underwent 184 CEAs. The remaining 443 patients (73%) had 491 CEAs. RESULTS: Patients with CRI were different in age (76 +/- 8 years vs 72 +/- 9 years, P < .001), male gender (73% vs 51%, P < .001), coronary artery disease (50% vs 28%, P < .001), and diabetes mellitus incidence (38% vs 27%, P < .02). No significant difference in stroke rates was observed between the CRI patients and the control group (1.2% vs 0.5%). The mortality rate for CRI patients was 3%, whereas it was 0% for the control group ( P < .002). The 143 CRI patients with serum creatinine levels from 1.5 to 2.9 mg/dL had a 0.7% mortality rate, whereas it was 17% for 23 patients with serum creatinine levels of 3 mg/dL or more ( P < .001). The stroke rate for the former group was 0.7% and 4.3% for the latter group (NS). Asymptomatic (16) and symptomatic (7) patients with serum creatinine levels of 3 mg/dL or more had mortality rates of 13% and 28%, respectively, with P = .6. CONCLUSION: The high mortality rate observed in patients with serum creatinine levels of 3 mg/dL or more after CEA calls for a nonoperative approach in the management of asymptomatic patients.

Duplex arteriography prior to femoral-popliteal reconstruction in claudicants: a proposal for a new shortened protocol.

The standard preoperative duplex arteriography (DA) from the aorta to the pedal vessels is time consuming and may be unnecessary in patients presenting with calf claudication alone. The feasibility of a shortened protocol was evaluated. Of 286 femoral-popliteal reconstruction based on DA during the last 4A years, 79 (28%) were primary operations for calf claudication. Eliminating the aortoiliac portion of the test except for the distal external iliac artery and limiting the scanning of the infrapopliteal vessels to one or two arteries in the leg would significantly shorten the exam. To confirm the adequacy of the inflow tract, we relied on the common femoral artery Doppler waveform analysis and the intraoperative graft pressure upon completion of the bypass. Of the 79 primary femoral-popliteal bypasses, 53 (67%) had triphasic common femoral artery waveform and the remaining 26 had monophasic or biphasic waveforms. Three (6%) of the 53 femoral-popliteal bypasses in the former group had significant pressure gradients measured intraoperatively and were treated with iliac angioplasties and stents for unsuspected stenoses in 2 cases and a covered stent for a common iliac aneurysm in 1 case. Three, two, and one infrapopliteal vessel runoff was observed in 24 (45%), 16 (30%), and 9 (17%) extremities, respectively. Four patients (8%) had significant stenoses (>50%) or occlusion of all three infrapopliteal arteries. Eighty-one percent of the patients would have completed the short protocol had we scanned the peroneal artery initially. An additional 8% would have required scanning of a second vessel (anterior tibial) and only 11%, scanning of all three infrapopliteal vessels. The time interval for completion of short-protocol DA was significantly less than the time for the standard DA (16.2 A+/- 5.2A min vs. 35.1 A+/- 10.6 min) ( p < 0.01). We believe that the proposed short DA protocol combined with intraoperative graft pressure measurements can be used in 94% of the patients who have a patent popliteal artery (>/= 7 cm). It is a totally noninvasive approach that is particularly suitable for vascular technologists and surgeons who wish to start utilizing DA instead of contrast arteriography prior to infrainguinal reconstructions. However, the short protocol does not avert the need for completion arteriography of the inflow arteries and readiness to perform endovascular procedures to correct lesions not suspected by common femoral artery waveform analysis.

Deep venous thrombosis after radiofrequency ablation of greater saphenous vein: a word of caution.

PURPOSE: Radiofrequency ablation (RFA) of the greater saphenous vein (GSV; "closure") is a relatively new option for treatment of venous reflux. However, our initial enthusiasm for this minimally invasive technique has been tempered by our preliminary experience with its potentially lethal complication, deep venous thrombosis (DVT). METHODS: Seventy-three lower extremities were treated in 66 patients with GSV reflux, between April 2003 and February 2004. There were 48 (73%) female patients and 18 (27%) male patients, with ages ranging from 26 to 88 years (mean, 62 +/- 14 years). RFA was combined with stab avulsion of varicosities in 55 (75%) patients and subfascial ligation of perforator veins in 6 (8%) patients. An ATL HDI 5000 scanner with linear 7-4 MHz probe and the SonoCT feature was used for GSV mapping and procedure guidance in all procedures. GSV diameter determined the size of the RFA catheter used. Veins less than 8 mm in diameter were treated with a 6F catheter (n = 54); an 8F catheter was used for veins greater than 8 mm in diameter (n = 19). The GSV was cannulated at the knee level. The tip of the catheter was positioned within 1 cm of the origin of the inferior epigastric vein (first GSV tributary). All procedures were carried out according to manufacturer guidelines. RESULTS: All patients underwent venous duplex ultrasound scanning 2 to 30 days (mean, 10 +/- 6 days) after the procedure. The duplex scans documented occlusion of the GSV in 70 limbs (96%). In addition, DVT was found in 12 limbs (16%). Eleven patients (92%) had an extension of the occlusive clot filling the treated proximal GSV segment, with a floating tail beyond the patent inferior epigastric vein into the common femoral vein. Another patient developed acute occlusive clots in the calf muscle (gastrocnemius) veins. Eight patients were readmitted and received anticoagulation therapy. Four patients were treated with enoxaparin on an ambulatory basis. None of these patients had pulmonary embolism. Initially 3 patients with floating common femoral vein clots underwent inferior vena cava filter placement. Of the 19 limbs treated with the 8F RFA catheter, GSV clot extension developed in 5 (26%), compared with 7 of 54 (13%) limbs treated with the 6F RFA catheter (P =.3). No difference was found between the occurrence of DVT in patients who underwent the combined procedure (RFA and varicose vein excision) compared with patients who underwent GSV RFA alone (P =.7). No statistically significant differences were found in age or gender of patients with or without postoperative DVT (P = NS). CONCLUSION: Patients who underwent combined GSV RFA and varicose vein excision did not demonstrate a higher occurrence of postoperative DVT compared with patients who underwent RFA alone. Early postoperative duplex scans are essential, and should be mandatory in all patients undergoing RFA of the GSV.

Intraoperative carotid artery duplex scanning in a modern series of 650 consecutive primary endarterectomy procedures.

PURPOSE: Thromboembolic complications after carotid endarterectomy are frequently associated with technical defects. We analyzed the effect of intraoperative duplex scanning in detection of significant but clinically unsuspected technical defects and residual common carotid artery (CCA) disease as a potential source of postoperative transitory ischemic attack (TIA) and stroke. METHODS: From April 2000 to April 2003, 650 consecutive primary carotid endarterectomy procedures were performed in 590 patients at a single institution by two vascular surgeons. Patients included 335 men (57%) and 255 women (43%). Indications for surgery were asymptomatic internal carotid artery (ICA) stenosis (>or=70%) in 464 patients (71%). All procedures were performed with the patient under general anesthesia, with synthetic patch angioplasty in 644 (99.1%). Major technical defects at intraoperative duplex scanning (>30% luminal internal carotid artery stenosis, free-floating clot, dissection, arterial disruption with pseudoaneurysm) were repaired. CCA residual disease was reported as wall thickness (0.7-4.8 mm; mean, 1.7 +/- 0.7) and percent stenosis (16%-67%; mean, 32% +/- 8%) in all cases. Postoperative 30-day TIA, stroke, and death rates were analyzed. RESULTS: There were no clinically detectable postoperative thromboembolic events in this series. All 15 major defects (2.3%) identified with duplex scanning were successfully revised. These included 7 intimal flaps, 4 free-floating clots, 2 ICA stenoses, 1 ICA pseudoaneurysm, and 1 retrograde CCA dissection. Diameter reduction ranged from 40% to 90% (mean, 67 +/- 16%), and peak systolic velocity ranged from 69 to 497 cm/s (mean, 250 +/- 121 cm/s). Thirty-one patients (5%) with the highest residual wall thickness (>3mm) in the CCA and 19 (3%) with the highest CCA residual diameter reduction (>50%) did not have postoperative stroke or TIA. Overall postoperative stroke and mortality rates were 0.3% and 0.5%, respectively; combined stroke and mortality rate was 0.8%. One stroke was caused by hyperperfusion, and the other occurred as an extension of a previous cerebral infarct. No patients had TIAs. Two deaths were caused by myocardial infarction, and one death by respiratory insufficiency. CONCLUSION: We believe intraoperative duplex scanning had a major role in these improved results, because it enabled detection of clinically unsuspected significant lesions. Residual disease in the CCA does not seem to be a harbinger of stroke or TIA.

Small popliteal artery aneurysms: are they clinically significant?

OBJECTIVE: We undertook this study to determine whether popliteal artery aneurysm diameter correlates with initial symptoms and presence of associated occlusive disease. METHODS: Duplex arteriography before infrainguinal revascularization in 500 lower extremities enabled diagnosis of 34 popliteal aneurysms in 25 patients (24 male, 1 female) over the last 4 years. Fourteen patients (41%) had no symptoms (group 1) and 20 (59%) had symptoms (group 2) of severe claudication (n = 8), acute ischemia (n = 6), rest pain (n = 2), and tissue loss (n = 4). We compared clinical presentation with popliteal artery diameter, prevalence of thrombosis, and presence of associated occlusive disease. RESULTS: Popliteal artery aneurysm diameter averaged 2.8 +/- 0.7 cm (range, 1.8-4.5 cm) in group 1 and 2.2 +/- 0.8 cm (range, 1.3-4.0 cm) in group 2 (P <.03). Popliteal aneurysm thrombosis was present in 7 of 20 limbs in group 2. Four of these patients also had ipsilateral superficial femoral artery thrombosis. Evaluation of the infrapopliteal arteries in group 1 showed three-vessel runoff in 7 limbs, two-vessel runoff in 3 limbs, one-vessel runoff in 2 limbs, and no vessel runoff in 2 limbs. However, all infrapopliteal arteries were either occluded or significantly stenotic in 14 limbs (70%). In group 2, one-vessel runoff was observed in 5 limbs, and two-vessel runoff in 1 limb. CONCLUSIONS: Smaller popliteal artery aneurysm was associated with higher incidence of thrombosis, clinical symptoms, and distal occlusive disease. Liberal use of duplex scanning in this setting may have accounted for the increased awareness that small popliteal artery aneurysms can thrombose and present with severe ischemia.

Cerebral hyperperfusion syndrome after carotid endarterectomy: predictive factors and hemodynamic changes.

PURPOSE: It is believed that cerebral hyperperfusion syndrome (CHS) is caused by loss of cerebral autoregulation resulting from chronic cerebral ischemia and that factors including increased intraoperative cerebral blood flow, ipsilateral or contralateral carotid disease, and postoperative hypertension may cause CHS. We describe our experience with CHS, which diverges from published reports. MATERIALS AND METHODS: From March 2000 to February 2002 we performed 455 carotid endarterectomy (CEA) procedures in 404 patients at our institution. CHS developed 1 to 8 days (mean, 3.2 +/- 2.5 days) postoperatively in 9 patients (2%), 6 women and 3 men, whose age ranged from 52 to 84 years (mean, 69 +/- 8 years). Indications for surgery in 8 patients without neurologic symptoms were ipsilateral internal carotid artery (ICA) stenoses ranging from 70% to 99% (mean, 80% +/- 7%); the remaining patient had an ipsilateral stroke, with good clinical recovery, 7 weeks before CEA. Only 1 patient had significant contralateral ICA stenosis (70%). However, 5 patients had undergone contralateral CEA within the previous 3 months. CHS symptoms were severe headache in 5 patients, seizures in 3 patients (1 stroke), and visual disturbance and ataxia in 1 patient. All 404 patients (455 cases) underwent intraoperative and early (2 weeks) postoperative carotid artery duplex scanning. The 9 patients with CHS also underwent carotid artery duplex scanning at the time of the neurologic event. RESULTS: Mean intraoperative ICA volume flow (MICAVF) in the 9 CHS cases was not significantly different from that in the other 446 cases (170 +/- 47 mL/min and 182 +/- 81 mL/min, respectively). However, mean ICA volume flow (481 +/- 106 mL/min) and peak systolic velocity (PSV) (108 +/- 33 cm/s) for the 9 CHS cases measured at onset of symptoms were higher than those for the remaining 446 cases (267 +/- 87 mL/min and 80 +/- 26 cm/s, respectively) (P <.01). Of the 9 patients with CHS, only 3 had systolic blood pressures more than 160 mm Hg at onset of symptoms. Severity of ipsilateral and contralateral ICA stenoses was not significantly different between the 9 CHS cases and the remaining 446 cases. CONCLUSIONS: These data do not corroborate the common belief that CHS occurs preferentially in patients with severe ipsilateral or contralateral carotid disease, increased intraoperative cerebral perfusion, or severe hypertension. Recently performed contralateral CEA (<3 months) appears to be predictive of CHS.

Splenic rupture from metastatic granulosa cell tumor 29 years after curative resection: case report and review of the literature.

Granulosa cell tumors account for 2 to 3 per cent of all ovarian neoplasms. This case report describes a patient with splenic rupture from a bulky metastatic deposit 29 years after her initial surgery. A review of the literature regarding the patterns and timing of recurrence is also discussed.